Neurological Injury in Intermediate-Risk Transcatheter Aortic Valve Implantation

BACKGROUND-The application of transcatheter aortic valve implantation (TAVI) to intermediate-risk patients is a controversial issue. Of concern, neurological injury in this group remains poorly defined. Among high-risk and inoperable patients, subclinical injury is reported on average in 75% undergoing the procedure. Although this attendant risk may be acceptable in higher-risk patients, it may not be so in those of lower risk. METHODS AND RESULTS-Forty patients undergoing TAVI with the Edwards SAPIEN-XTTM prosthesis were prospectively studied. Patients were of intermediate surgical risk, with a mean +/- standard deviation Society of Thoracic Surgeons score of 5.1 +/- 2.5% and a EuroSCORE II of 4.8 +/- 2.4%; participant age was 82 +/- 7 years. Clinically apparent injury was assessed by serial National Institutes of Health Stroke Scale assessments, Montreal Cognitive Assessments (MoCA), and with the Confusion Assessment Method. These identified 1 (2.5%) minor stroke, 1 (2.5%) episode of postoperative delirium, and 2 patients (5%) with significant postoperative cognitive dysfunction. Subclinical neurological injury was assessed using brain magnetic resonance imaging, including diffusion-weighted imaging (DWI) sequences preprocedure and at 3 +/- 1 days postprocedure. This identified 68 new DWI lesions present in 60% of participants, with a median +/- interquartile range of 1 +/- 3 lesions/patient and volumes of infarction of 24 +/- 19 mu L/lesion and 89 +/- 218 mu L/patient. DWI lesions were associated with a statistically significant reduction in early cognition (mean Delta MoCA -3.5 +/- 1.7) without effect on cognition, quality of life, or functional capacity at 6 months. CONCLUSIONS-Objectively measured subclinical neurological injuries remain a concern in intermediate-risk patients undergoing TAVI and are likely to manifest with early neurocognitive changes